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December 2017 (Volume 95)
Ezekiel J. Emanuel
Today, medical education is anachronistic. It remains largely governed by the Flexner model. Yet medical practice itself is in the midst of a transformation as significant as the one that stimulated the Flexner revolution in 1910. All aspects of medical education, from premedical requirements to clinical training, must also transform. Otherwise, tomorrow’s physicians will be ill prepared to deliver high-quality care.
Four Trends in Medical Practice and Education
Significant medical advances occurred in the late 19th century, including germ theory, antisepsis, anesthesia, and diagnostic tests, such as x-rays and the gram stain. Consequently, hospital-based care, especially surgery, became safer and more effective, and infectious diseases became identifiable and preventable. Flexner’s reforms ensured 20th-century physicians were able to deploy and enhance these advances. But these reforms are becoming increasingly obsolete, due to 4 inevitable trends (Table 1).
First, chronic diseases represent the dominant medical problem in the United States. Of the 10 leading causes of death in the United States, 7 are chronic illnesses, accounting for nearly two-thirds of deaths and 84% of all health care spending.1,2 Medical care of the future must focus less on acute, hospital-based interventions and more on compliance with medications, medical interventions, and lifestyle changes. Future physicians will need more training in psychology and behavioral economics to encourage these patient behaviors.
Second, while 20th-century care was hospital-based, outpatient care now dominates. Hospital admissions peaked in 1981 at 39.2 million (170 admissions per 1,000 people); in 2014, there were just 34.9 million hospital admissions (109 admission per 1,000 people), yet there were nearly 1 billion outpatient visits.3 Medical care of the future will be delivered outside the walls of medical facilities by interdisciplinary teams. Future physicians will need to be leaders trained in effective team management and care coordination.
Third, high-value care will be the norm. In 1960, medical care constituted just 5% of the US GDP; today, it is just under 18%. Pressure to deliver consistently higher-value care will grow. Future physicians will need training in intervention evaluation, operations management, and process improvement to develop and deliver standardized, high-value care.
Fourth, “science is growing exponentially . . . and doubles in size every 10 to 15 years.”4 The medical care of the future will be awash in information and will require structured information management to help providers offer well-informed care. Future physicians will need more training in the retrieval, management, and critical evaluation of relevant medical information.
While other trends, including standardization of care and real-time performance feedback, are also inevitable, these 4 trends are comprehensive enough to require revamping current medical education. My suggestions are summarized in Table 2. Without such changes, future physicians will be providing care more appropriate to the early 20th century.
Premed Requirements and Medical School Admissions
Medical education begins before matriculation. Prospective medical students are expected to take 13 semesters of prerequisite courses—more than 40% of all college courses. Many of these prerequisites—especially physics, organic chemistry, and calculus—are irrelevant to being a competent physician. These courses are not even good predictors of student performance; indeed, medical school performance may be better predicted by having a social science and humanities background.5
The recent changes to require statistics and recommend psychology courses are a good start. Being able to accurately present the value of treatments to patients requires an understanding of statistics. Similarly, trying to help people change their behaviors and habits and leading interdisciplinary teams involves a great deal of human psychology.
Thus, physics, calculus, and organic chemistry should be eliminated from both medical school admissions requirements and the MCAT. Medical schools should instead require statistics and psychology.
Preclinical Medical Education
Flexner’s suggestion of 2 years of preclinical science is still largely operative today. No one doubts the value of anatomy, microbiology, or pathophysiology. But many medical schools, including Harvard, Duke, and the University of Pennsylvania, have safely shortened preclinical training. All preclinical training should be limited to no more than 15 months.
Clinical Medical Education
Despite the predominance of outpatient visits, training remains largely hospital based. Caring for patients with the same underlying condition in different settings requires different knowledge bases and skills. Yet the training of medical students remains predominantly an inpatient activity, as if acute exacerbations requiring hospitalization are the “more important” part of medicine. The hospital focus of clinical clerkships may partially explain why the care of chronically ill patients is so poor.
One way to train students in the outpatient setting is to reinstitute the 19th-century practice of shadowing clinicians. Medical schools should identify talented clinicians, enhance their adult educational techniques, and incentivize them—financially and nonfinancially—to have medical students shadow them. Students would rotate among these different clinicians, learning how to manage different patient populations. The students would meet each week, either in person or virtually, for more formal didactic sessions.
Beyond Preclinical and Clinical Training
If preclinical training becomes 15 months and clinical training remains 2 years, what should be done with the extra time? One option is simply to reduce the total length of medical education to 3 years. No data show that 4 years of medical school is necessary to produce competent physicians.
Another option is to spend time training physicians in organization management and process improvement to identify waste and redesign processes of care. Such training could be introduced in the preclinical years, and the skills could be re-emphasized during classes following medical students’ core clinical experiences.
A third option is to require students to get a second degree. Which degree? Different types of physicians will need different sets of skills. Students focusing on population health might opt for a traditional MPH or MBA. Students attracted to end-of-life care might complete a master’s degree in bioethics. Students in primary care might opt for a master’s degree in behavioral economics or human psychology. Those medical students who focus on basic science research could still do a traditional MD-PhD program.
Today’s medical school students will be practicing through 2050. As medical practice changes, medical education will need to likewise adapt. Medical education of the future needs to eliminate physics, organic chemistry, and calculus as premed requirements, shorten preclinical training to 15 months, and shift more clinical clerkships to the outpatient setting. Medical school should be shortened to 3 years or should include adding additional training valuable to practitioners.
Ezekiel J. Emanuel is vice provost for global initiatives and chair of the Department of Medical Ethics and Health Policy at the University of Pennsylvania. From January 2009 to January 2011, he served as special advisor for health policy to the director of the White House Office of Management and Budget. Since 1997 he was chair of the Department of Bioethics at The Clinical Center of the National Institutes of Health and a breast oncologist. Emanuel received his MD from Harvard Medical School and his PhD in political philosophy from Harvard University. After completing his internship and residency in internal medicine at Boston’s Beth Israel Hospital and his oncology fellowship at the Dana-Farber Cancer Institute, he joined the faculty at the Dana-Farber Cancer Institute. He has since been a visiting professor at the University of Pittsburgh School of Medicine, UCLA, and New York University Law School, the Brin Professor at Johns Hopkins Medical School, and the Kovitz Professor at Stanford Medical School. Emanuel has written and edited 9 books and over 200 scientific articles. He is currently a columnist for the New York Times.
The “Great” Generation and a Not-So-Great Health System